Anne Lübbeke

Treatment of reverse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or a 95 degrees screw-plate: a prospective, randomized study

Background: Intertrochanteric fractures are composed of different anatomic patterns that vary in their degree of stability following open reduction and internal fixation. A particularly unstable group is classified as AO/OTA 31-A3, with the fracture pattern described as reverse oblique or transverse. The purpose of this study was to compare the results of intramedullary fixation with those of plate fixation for these intertrochanteric fractures in elderly patients.Methods: Thirty-nine elderly patients with AO/OTA 31-A3 intertrochanteric fractures of the femur were randomized into two treatment groups and were followed for a minimum of one year. The nineteen patients in Group I were treated with a 95° fixed-angle screw-plate (Dynamic Condylar Screw), and the twenty patients in Group II were treated with an intramedullary nail (Proximal Femoral Nail). The treatment groups were comparable with regard to all demographic and injury variables.Results: Patients treated with an intramedullary nail had shorter operative times, fewer blood transfusions, and shorter hospital stays compared with those treated with a 95° screw-plate. Implant failure and/or nonunion was noted in seven of the nineteen patients who had been treated with the 95° screw-plate. Only one of the twenty fractures that had been treated with an intramedullary nail did not heal.Conclusion: The results of our study support the use of an intramedullary nail rather than a 95° screw-plate for the fixation of reverse oblique and transverse intertrochanteric fractures in elderly patients.

Pertrochanteric fractures: is there an advantage to an intramedullary nail?: a randomized, prospective study of 206 patients comparing the dynamic hip screw and proximal femoral nail.

Objectives To compare the results between a sliding compression hip screw and an intramedullary nail in the treatment of pertrochanteric fractures. Design Prospective computer-generated randomization of 206 patients into two study groups: those treated by sliding compression hip screw (Group 1;n = 106) and those treated by intramedullary nailing (Group 2;n = 100). Setting University Level I trauma center. Patients All patients over the age of fifty-five years presenting with fractures of the trochanteric region caused by a low-energy injury, classified as AO/OTA Type 31-A1 and A2. Intervention Treatment with a sliding compression hip screw (Dynamic Hip Screw; Synthes-Stratec, Oberdorf, Switzerland) or an intramedullary nail (Proximal Femoral Nail; Synthes-Stratec, Oberdorf, Switzerland). Main Outcome Measurements Intraoperative: operative and fluoroscopy times, the difficulty of the operation, intraoperative complications, and blood loss. Radiologic: fracture healing and failure of fixation. Clinical: pain, social functioning score, and mobility score. Results The minimum follow-up was one year. We did not find any statistically significant difference, intraoperatively, radiologically, or clinically, between the two groups of patients. Conclusions There is no advantage to an intramedullary nail versus a sliding compression hip screw for low-energy pertrochanteric fractures AO/OTA 31-A1 and A2, specifically with its increased cost and lack of evidence to show decreased complications or improved patient outcome.

Prevalence of Neurologic Lesions After Total Shoulder Arthroplasty

BACKGROUND Clinically evident neurologic injury of the involved limb after total shoulder arthroplasty is not uncommon, but the subclinical prevalence is unknown. The purposes of this prospective study were to determine the subclinical prevalence of neurologic lesions after reverse shoulder arthroplasty and anatomic shoulder arthroplasty, and to evaluate the correlation of neurologic injury to postoperative lengthening of the arm. METHODS All patients undergoing either a reverse or an anatomic shoulder arthroplasty were included during the period studied. This study focused on the clinical, radiographic, and preoperative and postoperative electromyographic evaluation, with measurement of arm lengthening in patients who had reverse shoulder arthroplasty according to a previously validated protocol. RESULTS Between November 2007 and February 2009, forty-one patients (forty-two shoulders) underwent reverse shoulder arthroplasty (nineteen shoulders) or anatomic primary shoulder arthroplasty (twenty-three shoulders). The two groups were similar with respect to sex distribution, preoperative neurologic lesions, and Constant score. Electromyography performed at a mean of 3.6 weeks postoperatively in the reverse shoulder arthroplasty group showed subclinical electromyographic changes in nine shoulders, involving mainly the axillary nerve; eight resolved in less than six months. In the anatomic shoulder arthroplasty group, a brachial plexus lesion was evident in one shoulder. The prevalence of acute postoperative nerve injury was significantly more frequent in the reverse shoulder arthroplasty group (p = 0.002), with a 10.9 times higher risk (95% confidence interval, 1.5 to 78.5). Mean lengthening (and standard deviation) of the arm after reverse shoulder arthroplasty was 2.7 ± 1.8 cm (range, 0 to 5.9 cm) compared with the normal, contralateral side. CONCLUSIONS The occurrence of peripheral neurologic lesions following reverse shoulder arthroplasty is relatively common, but usually transient. Arm lengthening with a reverse shoulder arthroplasty may be responsible for these nerve injuries.

Value of Preoperative Investigations in Diagnosing Prosthetic Joint Infection: Retrospective Cohort Study and Literature Review

The diagnosis of a prosthetic joint infection is difficult, but crucial for appropriate treatment. Scintigraphy with specific markers for infection (labelled white cells or immunoglobulin-G) has been reported as a more reliable diagnostic tool than clinical assessment (fever, fistula), laboratory studies (polynuclear neutrophil count, erythrocyte rate sedimentation, and C-reactive protein), and preoperative aspiration. In the first part of this study, we retrospectively reviewed 230 patients admitted with a suspected prosthetic joint infection, and examined the validity of the different diagnostic tools for the group as a whole and for subgroups according to the Coventry classification. In the second part, we reviewed 35 articles about preoperative evaluation of infection in prosthetic joints and compared them to our findings. Our study indicates that C-reactive protein and joint aspiration are the most useful tools to diagnose prosthetic joint infection even in situations of chronic infection (Coventry type II).

Outcomes of obese and nonobese patients undergoing revision total hip arthroplasty.

OBJECTIVE To evaluate the effect of obesity on the incidence of adverse events (surgical site infection, dislocation, re-revision, or > or =1 adverse event), functional outcome, residual pain, and patient satisfaction after revision total hip arthroplasty (THA). METHODS We conducted a university hospital-based prospective cohort study including 52 obese and 152 nonobese patients with revision THA performed between 1996 and 2006. We used incidence rates, rate ratios, and hazard ratios (HRs) to compare the incidence of events in obese and nonobese patients and in 4 body mass index (BMI) categories (<25, 25-29.9, 30-34.9, > or =35). Functional outcome and pain were measured 5 years postoperative using the Harris Hip Score. RESULTS The incidence rate for > or =1 complication increased with rising BMI (1.8, 3.4, 10.3, and 17.9 cases/100 person-years). The increase was small between normal and overweight patients (adjusted HR 1.5, 95% confidence interval [95% CI] 0.5, 4.7), significantly greater with BMI 30-34.9 (adjusted HR 4.5, 95% CI 1.4, 14.0), and most evident with BMI > or =35 (adjusted HR 10.9, 95% CI 2.9, 41.1). The adjusted HR for surgical site infection (obese versus nonobese) was 4.1 (95% CI 1.1, 15.0) and for dislocation 3.5 (95% CI 1.3, 9.3). Eighty patients had a followup visit at 5 years. Obese patients had moderately lower functional results and higher levels of residual pain, but patient satisfaction was almost similar. CONCLUSION Revision THA is technically challenging, particularly in obese patients, probably due to more difficult anatomic conditions. We found an increased risk of adverse events, notably surgical site infection and dislocation in these patients.

Acromioclavicular and coracoclavicular cerclage reconstruction for acute acromioclavicular joint dislocations

BACKGROUND Little information is available on the results of the different stabilization techniques described for treatment of acute acromioclavicular (AC) joint injuries. Additionally, no studies have analyzed isometric performance of the shoulder after AC stabilization. The objective of our study was to present functional outcome including isokinetic testing and radiographic evaluation of patients treated with stabilization of AC joint dislocations. PATIENTS AND METHODS Thirty-seven patients with acute type III to V AC joint disruption underwent open coracoclavicular (CC) and AC stabilization with nonabsorbable sutures. RESULTS The mean follow-up was 4.5 ± 2.5 years (range, 2-10.5). The mean Constant score (CS) was 96. There were 34 (91.9%) excellent results, 1 good (2.7%), 1 satisfactory (2.7%), and 1 fair (2.7%). The disabilities of the arm, shoulder, and hand (DASH) questionnaire revealed good overall subjective evaluation with a mean of 7 points. The mean visual analog scale (VAS) pain score was 0.8. Patients with a CC distance <5 mm, or an anterosuperior AC reduction less than 50%, showed significantly better results in CS and DASH score in comparison to patients with a subluxated AC joint (P < .005). Twenty-two patients agreed to undergo isokinetic evaluation. We were unable to demonstrate any clinically significant difference between the involved and the uninvolved side. DISCUSSION The described technique of cerclage augmentation offers an attractive alternative in AC joint stabilization, with good to excellent results. In comparison to other techniques, there were no complications related to any implants, no graft donor site morbidity, or need for implant removal.

Fixed-bearing versus mobile-bearing total knee arthroplasty: A prospective randomised, clinical and radiological study with mid-term results at 7 years

Mobile-bearing (MB) total knee arthroplasty (TKA) was developed as an alternative to the established fixed-bearing (FB) design because of theoretical advantages. Short-term studies comparing these designs have not shown any differences in clinical and radiographic results. We compared the results at 7 years of a randomised study of patients undergoing TKA using either a FB or a MB variant of the same prosthesis. Fifty-two patients (52 knees) with an average age of 70 years received a FB posterior-stabilized prosthesis, and 50 patients (52 knees) with an average age of 72 years, a MB prosthesis. All implants were cemented and the patella was routinely resurfaced. Preoperatively, there were no differences between the two groups, and surgical procedure and postoperative protocol were the same for both. At an average follow-up of 7.1 years, no significant differences of FB over MB design could be demonstrated with respect to the American Knee Society score (AKSS), pain score, a questionnaire of general health (SF-12 score), range of motion (ROM), or complication rates. Radiographs showed no significant difference in prosthetic alignment or evidence of loosening. Two knees with a MB design required reoperation, one for persistent joint stiffness and another to treat septic loosening. One patient with a MB prosthesis with signs of tibial component loosening was asymptomatic. We conclude that at mid-term follow-up there is no evidence to prove the superiority of MB over FB TKA with regard to the clinical and radiographic results.

Influence of Arm Lengthening in Reverse Shoulder Arthroplasty

BACKGROUND Reverse shoulder arthroplasty (RSA) can improve anterior active elevation (AAE) by lengthening of the deltoid and hence increasing its lever arm. However, evaluations of functional outcomes of RSA have shown variable improvements in the range of motion. The aim of our study was to correlate humeral and arm lengthening to postoperative AAE. METHODS We reviewed 183 RSAs with a minimum follow-up of 1 year. Lengthening of the humerus and the arm was evaluated in relation to the contralateral side. RESULTS We observed mean humeral lengthening of 0.2 ± 1.4 cm (range, -4.7 to +5.2 cm) and mean arm lengthening of 1.6 ± 1.9 cm (range, -5.1 to +5.4 cm). Postoperative AAE was 140° ± 27° (range, 30° to 180°). We found no significant correlation between lengthening or shortening of the humerus and AAE (P = .169). Shortening of the arm led to a mean AAE value of 122°; lengthening of 0 and 1 cm, mean AAE of 140°; lengthening of greater than 1 cm to 2.5 cm, mean AAE of 144°; and lengthening of greater than 2.5 cm, mean AAE of 147°. When we compared patients with lengthening of the arm and those with shortening, the postoperative AAE was significantly greater after arm lengthening, 145° versus 122°, with a mean difference of 23° (95% confidence interval, 13° to 33°) (P < .001). CONCLUSION This study shows that shortening of the arm reduced AAE. With respect to arm lengthening, a lengthening threshold was not found. An objective assessment of deltoid lengthening is possible preoperatively, intraoperatively, and postoperatively, and this measure seems to correlate with the functional outcome.

Noninsertional Achilles Tendinopathy Treated with Gastrocnemius Lengthening

Background: Surgery is frequently considered an option for refractory, symptomatic noninsertional Achilles tendinopathy. Gastrocnemius equinus can result in mechanical overload of the Achilles tendon and may be a factor in its etiology. Our hypothesis was that reducing load transmission to the Achilles tendon by gastrocnemius lengthening (Strayer procedure) may be an effective treatment. Materials and Methods: A prospective case series of all patients with a minimum 1-year symptomatic nonin-sertional Achilles tendinopathy who underwent gastrocnemius lengthening was evaluated before surgery, and at 1 and 2 years after surgery. There were 14 patients (17 tendons). Results: One year after surgery, the median American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score was 100 points, as compared to 71 points preoperatively (p< 0.001). The median total Foot Function Index (FFI) decreased significantly from 39 to 12 points at 1 year (p< 0.001) and remained stable (12 points) at 2 years. An electronic goniometer recorded a mean gain in ankle dorsiflexion of 13 degrees. At 1 year after surgery the MRI in all eight patients (ten tendons) with a preoperative MRI demonstrated a decrease in signal hyperintensity and tendon size, signifying an improvement of the tendinopathy. At 2 years after surgery, patient satisfaction assessment revealed that all but one patient was satisfied with the result and 11 of the 14 (79%) patients were able to resume their previous sporting activities. There were no complications. Conclusion: Gastrocne-mius lengthening was an effective treatment for chronic Achilles noninsertional tendinopathy. Two-year results show good to excellent clinical outcome. Level of Evidence: Level IV, Prospective Case Series

Low incidence of haematogenous seeding to total hip and knee prostheses in patients with remote infections

OBJECTIVES The exposure of joint prostheses to remote infections is unknown. We wanted to estimate (a) the exposure of arthroplasty patients to severe remote infections, and (b) the incidence of arthroplasty infections associated with remote infections. METHODS Prospective cohort study of all elective hip and knee arthroplasties performed between March 1996 and September 2008, with retrospective documentation of remote infections in hospitalized patients. RESULTS A total of 6101 elective total joint arthroplasties, consisting of 4002 hip replacements (66%) and 2099 knee replacements (34%), were included. The mean follow-up was 70 months. During the study period, the cohort patients experienced 553 remote infections after a median delay of 33 months post-arthroplasty. There were 71 prosthetic infections detected, 7 (total incidence 7/6101, 0.1%) of which were secondary to a remote infection. The ratio of infections associated with remote infections to potential exposure was 1:79. Among hip arthroplasty patients the incidence rate was 1.4 infections associated with remote infections per 10,000 patient-years of follow-up. Infections associated with remote infections occurred later than surgical site infections, (46 months vs. 19 months post-surgery, respectively; mean difference 27 months, 95% CI 8-45 months). CONCLUSIONS Arthroplasty infections associated with remote infections were rare, and occurred like their potential exposure mostly more than 24 months post-arthroplasty.